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The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery?
- A. The client complains of a headache at '3' to '4' on a 1-to-10 scale.
- B. The client has an intake of 1,000 mL and an output of 3,500 mL.
- C. The client complains of a raspy, sore throat.
- D. The client experiences dizziness when trying to get up too quickly.
Correct Answer: B
Rationale: Significant output (3,500 mL) compared to intake (1,000 mL, B) suggests diabetes insipidus, a complication of craniotomy due to pituitary dysfunction. Mild headache (A), sore throat (C), and orthostatic dizziness (D) are less concerning.
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Which instruction should the nurse include for a client taking phenytoin (Dilantin)?
- A. Brush teeth gently to prevent gum hyperplasia.
- B. Avoid grapefruit juice.
- C. Take the medication with milk.
- D. Increase dietary sodium intake.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia; gentle brushing helps prevent gum complications.
Which sign or symptom in the client's medical history would most likely indicate a manifestation of the client's disease?
- A. Sudden hearing loss
- B. Sensitivity to light
- C. Drooping eyelids
- D. Protruding tongue
Correct Answer: C
Rationale: Drooping eyelids (ptosis) is a common symptom of myasthenia gravis due to muscle weakness affecting the ocular muscles.
The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority?
- A. Assess neurological status.
- B. Monitor pulse, respiration, and blood pressure.
- C. Initiate an intravenous access.
- D. Maintain an adequate airway.
Correct Answer: D
Rationale: Airway maintenance (D) is the highest priority in any critically ill patient, including those with head injuries, to ensure oxygenation. Neurological assessment (A), vital signs (B), and IV access (C) follow after securing the airway.
Which diagnostic test is used to confirm the diagnosis of Amyotrophic Lateral Sclerosis (ALS)?
- A. Electromyogram (EMG).
- B. Muscle biopsy.
- C. Serum creatine kinase (CK).
- D. Pulmonary function test.
Correct Answer: A
Rationale: EMG (A) detects abnormal muscle electrical activity characteristic of ALS, confirming the diagnosis. Muscle biopsy (B) is less specific, CK (C) may be elevated but isn’t diagnostic, and pulmonary tests (D) assess complications, not diagnosis.
The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply.
- A. Keep a record of seizure activity.
- B. Take tub baths only; do not take showers.
- C. Avoid over-the-counter medications.
- D. Have anticonvulsant medication serum levels checked regularly.
- E. Do not drive alone; have someone in the car.
Correct Answer: A,C,D,E
Rationale: Recording seizures (A) helps track treatment efficacy, avoiding OTC medications (C) prevents interactions, regular serum levels (D) ensure therapeutic dosing, and not driving alone (E) ensures safety. Tub baths (B) pose a drowning risk and are not advised.